A concierge or boutique label is discredits retainer medicine

Health care is in crisis. Reimbursements from insurance companies continue to dwindle, while the expenses of running an office continue to rise. Looming cuts in Medicare are only weeks away, and many physicians may stop taking Medicare. If these cuts go into affect, it is possible that primary care physicians could lose up to 50% of their salary. Just recently CNN reported that some doctors are going bankrupt.

How to fix our health care system is an ongoing debate, but not surprisingly, many physicians have decided not to wait for the government to solve this problem and have taken matters into their own hands. One solution is to simply stop taking insurance altogether. “Cash only” doctors are now commonplace in many major metropolitan areas. Another solution is charging a regular, out of pocket fee (usually) in addition to what insurance will pay for treatment. A version of this model that is becoming popular is called retainer medicine. Sometimes, retainer medicine is referred to a “boutique” or “concierge” even by physicians and others involved in health care (as evidenced by this article in American Medical News, which prompted me to post on this topic).

However, “retainer”, “concierge” and “boutique” are not the same thing. Names are important, and the terms “concierge” and “boutique” tend to have negative connotations. Thus, it is important to describe the differences.

In a retainer model, patients pay a fee (not covered by insurance) to be part of a physician’s practice. This is similar to clients paying a retainer fee to hire a specific lawyer. With reimbursements from insurance companies being so low, the only way an insurance based physician can increase revenues is to increase the volume of patients they see. Unfortunately, when physicians increase the number of patients they see, it leads to rushed patient visits, long waits in the waiting room, and decreased access to physicians including difficulty in getting appointments or responses phone call messages. By accepting a retainer fee, the physician no longer needs to rely on insurance revenue alone, and in fact can decrease the amount of patients he or she sees on a regular basis. This allows for increased access (usually same day or next day appointments and 24/7 phone access) and longer appointment times (usually 30-60 minutes) for patients willing to pay a retainer fee. The typical insurance based primary care physician has about 2500-3000 patients in their practice, and sees about 25 patients a day. The typical retainer physician has about 500 patients and sees only a handful of patients each day. Retainer fees and the amount of access patients get for what they pay vary widely, but the average retainer fee is about $1500 per year.

Some have argued that retainer medicine is unethical because not everyone can afford $1500 a year. First, the typical retainer fee amounts to about $4 a day, which is what many Americans pay (or more) for a Starbucks coffee. Secondly, one could also argue that it is also unethical for insurance based physicians to see complex patients in brief visits and/or not being able to see them in a timely fashion due to lack of access.

Concierge medicine is somewhat different, and in my opinion, should not be used synonymously with retainer medicine.

According to Wikipedia, “A concierge is an employee who either works in shifts within, or lives on the premises of an apartment building or a hotel and serves guests with duties similar to those of a butler. The term “concierge” evolved from the French Comte Des Cierges, The Keeper of the Candles, who tended to visiting nobles in castles of the medieval era.”

Just like the concierge at a hotel, who can get you good seats at a ticketed event, a reservation at a popular restaurant, or even run an errand; a concierge physician can get you timely appointments with the best specialists, usually doing the scheduling themselves. Many concierge physicians will even accompany patients to procedures or diagnostics tests, and some will even make house calls. Though some retainer practice physicians may perform concierge services (usually the ones charging well over the usual $1500 fee), the terms are not the same. Many retainer physicians will assist in coordinating specialist appointments, but this is as far as they go. In fact, some “cash only” physicians perform concierge services to attract more patients, and some doctors (even insurances based physicians) will charge an extra-fee for some concierge services, such as a house call.

Boutique medicine is also completely different. Again, from Wikipedia, “A boutique is a small shopping outlet, especially one that specializes in elite and fashionable items such as clothing and jewelry. It can also refer to a specialised firm such as a boutique investment bank or boutique law firm. In the strictest sense of the word, boutiques would be one-of-a-kind but more generally speaking, some chains can be referred to as boutiques if they specialize in particularly stylish offerings.”

I think the key words in this definition are “specilalized” “stylish” and “elite.” The first word is something commonplace in medicine, but the later two words are something usually not associated with medical practice. “Luxury” is also implied in the word “botique.” Thus, in my opinion, a boutique doctor is one that specializes in unique, often luxurious services, that are not offered by others and which will therefore cost a little extra. These services include, but are not limited to, cosmetic procedures (botox, laser hair removal), medical spa services, comprehensive screenings (i.e. body scans), and herbs or supplements. Though both retainer and concierge physicians may provide boutique services, this is generally not the norm. In fact, many insurance based primary care physicians have started to add these services as a way of keeping their practice running. (Ethics could be questioned here as well).

I am not arguing that retainer medicine is the solution for all of our nation’s health care woes. It certainly is not. However, given that it solves some of the issues with 3rdparty payors, is a model that continues to grow, and patients and providers enrolled seem to be very satisfied; it is something that deserves attention. Another model that is garnering some attention is direct access primary care. In this model, patients pay a monthly fee (usually about $70/month) and receive enhanced access and communication as well as primary care and urgent care services. Though the cost is slightly less ($1500/yr vs. $840/yr) and access to your personal may not be 24/7, this is a similar model to the retainer concept. (Proponents have called this retainer medicine for the masses).

Thus, using terms “concierge” and “boutique” that have connotations of elitism, luxury and unnecessary care synonymously with retainer medicine discredits a potentially viable health care model for many Americans. I would request that physicians, policy makers and journalists no longer use these terms as if they were the same.

Matthew Mintz is an internal medicine physician and blogs at Dr. Mintz’ Blog.

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http://twitter.com/bfabbio Bob Fabbio

Using the terms above, WhiteGlove Health is a membership-based business (retainer) giving members access to medical care 365 days a year. The difference is the membership fee is $100s a year and we bring care to our member’s home or workplace (concierge). And our acute care visits are all inclusive of generic Rx meds and incidentals.

The truth is we do not like the concierge label because it does connotes affluent. We have built an affordable model that caters to the masses.

In order to deliver the quality of experience we do, at the price point we are able, you have to automate everything with technology. That is what we have done.

My point is that healthcare needs new models like this in order to lower cost, improve access, and clinical outcomes. But, does not have to fall into the buckets described.

Anonymous

When I got divorced I paid a retainer fee to my attorney of 10K and what we did not use was refunded to me. This is not the case in retainer medicine. Still think you need a better descriptor for this type of practice.

http://www.capko.com Laurie Morgan

I agree with you. I also think “retainer” is not an accessible enough term for the general public. Maybe “subscription” or “membership” (sort of like Kaiser uses — you’re a member).

http://twitter.com/normwu Norm Wu

Thanks for drawing attention to the different models that have emerged to deal with the hamster wheel that providers face when accepting insurance reimbursement alone for primary care.

There is a growing “direct primary care” movement where the providers charge a low, flat monthly fee *in lieu of insurance* for unrestricted care. Thus, the model may be different from what is described as direct access primary care in that the providers do not take insurance at all in order to reduce overhead. All the fees go towards care, so monthly fees can be quite low. Some direct primary care practices like Qliance which I co-founded offer same day unhurried appointments seven days a week and do everything from routine primary and preventive care to urgent care, chronic disease management and coordination of all specialist and hospital care. It too is often confused with concierge medicine. However, at $49 to $89/month, it is intended to make great care and access affordable to almost individual and group.

Here we go again. Threats to not take Medicare patients because you can’t get rich. As if our elderly seniors don’t have enough to worry about. This is a perfect example of why any doctor that refuses Medicare patients should be excluded from participating and seniors should be given the opportunity to join an Accountable Care Organization (ACO). Under the Affordable Care Act, ACOs will begin to proliferate in a few short years. That process should be speeded up so that seniors aren’t insulted any longer and so they aren’t constantly made to worry by greedy doctors. Currently, there are nearly 50 trial ACOs running all across America and the preliminary results are very good. The fee-for-service delivery is abandoned in the ACO model. These are big-box operations with salaried employees. They are patient rated. The motive of the ACO delivery model is no longer the volume of tests, procedures and medicines, the new motive is wellness and good outcomes. Seniors have been insulted for long enough. They should be given the chance to tell greedy and insulting doctors that they are fired! Soon seniors will be encouraged to go to the future WalMart and the future Home Depot of health care delivery, their local ACO. These small office single-doc practices will soon see that they will be faced with the type of competition that will force them out of business. Who’s to blame? Greedy doctors that refuse elderly Medicare patients.

http://www.facebook.com/RebeccaCoelius Rebecca Coelius

I grow tired of your repetitive, uninformed comments calling doctors greedy on every primary care related article on KevinMD. Yes fee for service is an evil. You will find almost no primary care physician that would disagree with that. But you conflate how fee for service, sub speciality centric medicine has screwed primary care and destroyed access for seniors with a physicians lack of alturism.
Do you know who founded the integrated systems that are the models for ACOs that you so adore? (Kaiser, GroupHealth) Doctors. Because we think the system is hurting our patients too, and its making our careers in primary care untenable. Would you be so cavalier about your own salary or benefits being severely cut year to year with no recourse? Quality primary care is one of the most cost effective places to put your money in our healthcare system, why you would support further scapegoating it when the real culprit is the massive amount of money spent on things like costly and often unnecessary hospital-based care, heart caths, or back surgeries is beyond me. If you want the brightest people in our society to go into medicine you had best stop treating them like indentured servants, especially in primary care. Yes there is a huge place for NPs, RNs, MAs, and even people who often have no medical training but are great are crunching population data or serving as system navigators to fill roles in primary care and ALL of medicine previously held by MDs. But you still need somebody with a broad and deep medical training to efficiently make the initial diagnosis when a patient’s presentation is outside the algorithm taught in mid-level training programs, and in our elderly who often have many complex illnesses at the same time.

I’d also note that subspeciality care is actually one of the best places for mid level providers, or even more interesting to ask if the training paths for MDs destined there should be different from those destined for generalist medicine. The scope of information to be mastered for some (though not all) subspecialties is significantly narrower but deeper. Our medical training confuses the general public on this point because it forces MDs who will spend the rest of their lives performing cataract surgery to also learn all of internal medicine, birth babies, and other asinine things. Sure some breadth before specializing is important, but don’t think for a second that your orthopedic surgeon is the person you want to see see to diagnose your heart murmur just because they have been in training for over a decade. Its time we ask why all future clinicians are shunted through the exact same training programs with extra years just thrown on top at the end.

Anonymous

The current delivery of health care is still small office boutique health care. There’s nothing efficient about having hundreds of small one-doc practices in a geographical area when we can have five of six big-box state-of-the-art health care department stores. We simply can’t afford the current delivery model. Consumers are angry! Health care delivery must change and it will. Smart providers will plan and prepare for the future. The others will be forced out of business. Simple as that! By the way, I could care less how tired you are growing. The truth is still the truth. Put as much lipstick as you want on the current health care delivery model, a pig is still a pig!

http://pulse.yahoo.com/_2LRZNHDZS6DU45WQ567LPQ7CMI ninguem

” There’s nothing efficient about having hundreds of small one-doc
practices in a geographical area when we can have five of six big-box
state-of-the-art health care department stores.”

There is NO EVIDENCE for that, and in fact, there is evidence to the contrary, that medicine is most efficiently delivered in a solo or small group model. At least for primary care, it may not necessarily apply to specialty care.

What the big box places do, in fact, is use their size to extract higher payment from the insurance plans, and drive up the cost of care. They do well, not because of efficiency (lower cost), but because they can extract the higher payments.

Anonymous

No evidence? You need only to look at what Home Depot did to the local hardware stores and the small neighborhood construction suppliers. You need only to see what WalMart did to the local grocery stores and the local pharmacies. Everything under one roof, as the ACO model will soon provide, there’s much more efficiency and economy of scale. A moron would believe otherwise. We are seeing today that bog-box pharmacies are negotiating with drug companies (actually telling drug companies) what they will pay for drugs. Today, most big-box pharmacies routinely offer $4 generics. I see ACOs doing the exact same thing. Negotiating for drugs and negotiating for all medical supplies. This will force prices down for consumers over time. Face it, the game is coming to an end. The goose that lays those golden eggs is dead. You’ve had your party. You’ve had a great run. You’ve gotten very wealthy at the expense and worry of the elderly and other health care consumers. To be honest, you have worried many Medicare patients to death. That’s not a figure of speech! Consumers aren’t happy. Consumers have been abused by a broken health care system for far too long.

“What the big box places do, in fact, is use their size to extract higher payment from the insurance plans, and drive up the cost of care. They do well, not because of efficiency (lower cost), but because they can extract the higher payments.”

That’s absurd! I pay less today for a box of nails than I did 20 years ago. I love my Home Depot!

http://pulse.yahoo.com/_2LRZNHDZS6DU45WQ567LPQ7CMI ninguem

This is not Home Depot, it’s primary care. Where is the economy of scale in primary care? Show me where that’s happening in the business of medical services. Not the Wal-Mart four dollar generics. Not the box of nails. Medical services.

Fact is, as my PCP so often explains to me, 85 percent of primary care is routine and can be done by an RN or a NP or a PA. The remaining 15 percent gets referred out to a specialist. Most of primary care is not rocket science. That’s why, in the military, they call it triage and they have enlisted people doing it.

http://pulse.yahoo.com/_2LRZNHDZS6DU45WQ567LPQ7CMI ninguem

You’re not picking, you’re just being an obnoxious jerk.

None of this addresses the point. Primary care is more efficiently delivered in a solo or small group setting. That would be true even if delivered by midlevels, your latest change of subject. The evidence is out there, you’ve provided no evidence to your point except irrelevancies and childish namecalling.

You don’t have a clue, you don’t care to have a clue. I’m wasting my time with the likes of you.

Anonymous

Gee, if I have offended you delicate sensibilities, I would like to apologize.

http://www.facebook.com/RebeccaCoelius Rebecca Coelius

Actually, much of medical care is moving away from the “everything under one roof” hospital model. Most health economists point to this as being one of the biggest drivers of healthcare costs. Outpatient diagnostic centers and surgery centers are two examples of disruptive business models that have driven down the cost of care. Doc in a box acute care practices are doing a similar thing for much of primary care.

Wal Mart won because it was expert at distribution networks, and could leverage its enormous amount of buying power to out price mom and pop stores. Really not the same thing.

Daniel Wann

One problem with ACOs is that since they employ both primary care docs and specialists, what’s to stop them from trying to maximize profit by pressuring the primary care docs to refer more and more? That way, they can get a billing from the primary care doc, and another from the specialist. They may even be able to get a procedure out of it.

Anonymous

Everyone is a salaried employee in an ACO. In the ACO world, the fee-for-service model is completely abolished. The ACO gets a set dollar amount per patient whether the patient is sick or well. There is no “billing”. The incentive isn’t to bill patients for the volume of referrals, visits, tests or procedures any longer. In the ACO, you don’t get paid more just because you do more. Fact is, needing to do more volume works against the profit of the ACO team since they only get a set amount per patient. As a team, an ACOs mission is to get the patient healthy and keep them healthy. A successful ACO team is one with many patients on the patient list but few in the waiting room. A perfect ACO is one that has all of their patients relatively healthy and not requiring any significant treatment except preventive treatment. The idea is to strive for wellness and good outcomes on the set dollar amount per patient. Oh, by the way, cherry picking is not allowed if you want to be sanctioned as an ACO. Certified ACOs can not discriminate like small office boutique docs do today. Today, small office fee-for-service docs threaten to refuse taking Medicare patients because they aren’t getting paid enough. That is not allowed in the ACO model.

Anonymous

From “A Guide to ACOs” article you recommended:

” The physicians submit their traditional claims to Medicare under the RBRVS system while the hospital submits its typical DRG-base claim. Thus, the traditional fee-for-service system remains in place. At the end of the year, Medicare determines if the ACO has provided care for less than $10,000. If they have, the ACO is entitled to share in the cost savings, and the savings are divided among the providers and hospital.”

Fee for service is not eliminated. ACOs are not capitated. All the physicians are not employees of the ACO. Everything is not under one roof.

Bobby Maz

“But you still need somebody with a broad and deep medical training to efficiently make the initial diagnosis when a patient’s presentation is outside the algorithm taught in mid-level training programs, and in our elderly who often have many complex illnesses at the same time. ”

Your statement is both ignorant and insulting, clearly showing how little you know about “Mid-Level Training Programs.”

http://www.facebook.com/RebeccaCoelius Rebecca Coelius

Actually not true, I know an enormous amount about mid level training programs. I have a huge amount of respect for what they do well and advocate at every move that they work at the top of their license. However I’m not going to pretend that the exceptionally limited number of clinical hours and other aspects of the abbreviated training makes mid levels well equipped to deal with a certain percentage of undifferentiated and most medically complex patients. Your training ends right around that of a third year medical student. Sorry, not the same, but that doesn’t mean you aren’t immensely important members of the healthcare team. And I don’t necessarily put the physician at the “top” of that team- I think we can be equals and each have our own focus in the practice.

Really Dave??? How many ACO’s are running in senior citizen rich areas ? Anecdotal data is all that is available at this point. I ran a traditional internal medicine practice for 25 years and saw government regulations raise the cost of doing business to 65 cents on a dollar. I am not sure which rich greedy physicians you are referring to but sitting up at night every other week sweating whether you and your physician partner, seeing 150 patients each per week , can meet payroll isnt exactly getting rich on the backs of your patients. Sitting down with your spouse and discussing whether you can take home a paycheck isn’t very conducive to having a clear mind while providing patient care either. The reality is that patients seeing senior citizens in primary care in areas heavily dependent on Medicare struggled to survive in the nineties and first decade of the new century. While ACOs run by hospital systems may be financially solvent because the Feds won’t let them fail, it remains to be seen whether patient longitudinal care occurs, whether outcomes are equal to fee for service care and whether these new entities can actually attract and keep medical doctors in primary care.
Retainer medicine gives patients an opportunity to take control of their relationship with their physician by choosing a service oriented physician. It gives the physician the time and resources to provide long term preventive and health care to patients. It remains to be seen whether the ” team approach” of ACO’s is anything other than a government mandated version of the Lucy Arnez , Ethel Mertz conveyor belt cake episode?

Anonymous

Tears are welling up as I read your post. Can I borrow your hankie? Fact is, what Home Depot did for home improvement consumers and what WalMart did for retail consumers, ACOs and big-box health care is going to do for health are consumers all across. Small hardware stores and small grocery stores are virtually extinct in my area. Will it happen tomorrow for health care? Nope! But it’s gonna happen. The current broken fee-for-service health care delivery system must change! Those in denial refuse to see that. What broke it? Decades of greed! There’s over 50 million Americans that are uninsured and totally excluded from the health care system you’ve helped to create. That number grows larger every single day. Why? BECAUSE WE CAN’T AFFORD OUR EXPENSIVE BOUTIQUE STYLE HEALTH CARE DELIVERY SYSTEM ANY LONGER! Oh, by the way, did I mention that there’s an additional 25 million more Americans that are underinsured and don’t know it until they go to use their lousy insurance plan? Providers and insurers had a chance to make it right and clean it up, but they didn’t. The money was just too darn good and greed took over. As long as the cow was giving milk, you milked it! Guess what? The cow is on life support! Consumers are angry. I wish you well as you try to survive the fierce competition that’s coming soon for small operators. My PCP says he can’t compete. He says the plans that hospital groups have in our area are simply too aggressive. There are five hospital groups that comprise about twenty hospitals and each group is going full steam ahead with plans to create an ACO. Like you, he’s scared. So, he’s going to sell his practice and join them.

Nobody asked for your tears or sympathy. I wish your doctor luck in selling his practice to the hospital system. In my thirty years of experience I have seen hospital systems buy up practices two times previously, pay top dollar to the physicians, run the practice into the ground through mismanagement losing millions of dollars and then they give it back to the practitioner to run on his own at no charge for the return of the practice. This would include a corporate health system and a community hospital system.
I wish you luck as you age in obtaining time , care and compassion in a conveyor belt system populated by health care extenders with physicians working primarily in a supervisory or managerial role.
If there is greed in the health care system it is equally shared by pharmaceutical manufacturers, hospital systems, durable medical equipment companies, insurance companies ,employers, physicians and to a large degree patients. There is plenty of blame to go around.
The direct pay or retainer model of medical care was an innovation that developed because there was a need and a niche to be filled and the employers who wanted quality for their buck but didnt know how to define it, sold out to the insurers who sold them the promise of accountability in areas they do not have a clue what they are talking about. They know how to make money. They know how to cover their risk. They don’ t have a clue or give a hoot about anything other than their profit after expenses. Hospital systems are not much better. Its convenient to blame the providers actually doing the day to day care because in primary care they are so busy treating patients in volume to pay the bills that they don’t have time to lobby and they dont have the cash to hire others to do it for them as aggressively as the specialty societies do.
Direct pay practice is about paying a fair fee for a service without the insurance company interfering. The reason they are successful is that there is a demand for them which will increase

Samir Qamar

Good, informative article. As having owned and operated a “VIP practice” in California, I can attest to the negative connotations associated with labeling such practices as “concierge” or “boutique.”

There is an affordable alternative – direct primary care. As Mr. Wu of Qliance and Mr. Fabbio of WhiteGlove Health have pointed out, excellent medical care does not necessarily come with high fees. In fact, direct primary care practices have effectively demonstrated that the model can minimize expensive, complicated downstream costs if quality primary care is made more accessible. Thus patients, even seniors, can enjoy quality medical care for less. For example, at our MedLion Direct Primary Care practices, seniors pay just $39 a month for visit times triple the national average, telemedicine for when they’re ill, and overall high-impact primary care. They still use their Medicare when needed for complex care. Care begins at just $19 a month for dependents, and $59 for non-senior dependents. Care is always by doctors.

At MedLion, we take it a step further. We believe that in addition to patients, doctors are also victims in the current system. Primary care doctors wishing to use MedLion’s model in their own practices are welcome to do so – MedLion guides them through the whole process, ensuring airtight medico-legal compliance. Most importantly, our doctors keep most of their practice the way it is, including many of their insurance contracts. The result is that all full capacity (still half the national average) our MedLion doctors are relaxed, happier, and generate significantly more revenue for their private practices. Patients choosing to pay MedLion’s reasonable fees are likewise happier, and because there is less barrier to access, also healthier.

Anonymous

Two of the most important things a primary care physician
can do are 1) give really complete preventive medicine and 2) coordinate the
care of those with chronic illnesses. Neither tend to be done well or thoroughly
in the usual practice model of 1500 or more patients. There is just not enough
time and no time to just “think.”

Retainer based practices are able to do both of these because
the physician has the time needed. Sure, a lot of primary care can be
accomplished in just a few minutes or with the assistance of a nurse practioneer
or other well trained provider. But the really important stuff is still the
province of the physician. Taking time to talk to a patient about life style
changes for example just cannot be done quickly and still have an impact.

And the patient with chronic disease needs to have their
referrals to specialists carefully coordinated; same with tests, imaging and procedures.
When there is not enough time, referrals to specialists goes up dramatically
when the problem could have been figured out with some more probing by the PCP.
The result is referrals go down, testing goes down and costs go down. Most importantly,
quality goes up as does both patient and physician satisfaction.

It a win-win for all. Yes it costs more but the return on investment
– provided the retainer based physician actually does coordinate care and
actually takes time with preventive care – is quite substantial.

Stephen C Schimpff, MD

Anonymous

Good post…

Maybe if doctors spent more time being “doctors” and less time coordinating the daily business of running a small one-doc office with several staff people to pay and coordinate, heating bills to pay, telephone bills to pay, electric bills to pay, computer systems to maintain, telephone systems to maintain, building mechanicals to maintain, purchasing and maintaining EHR systems, etc., etc., etc., your patients might just get “all” of your undivided attention. Gee, I have a great idea! Toss all of that, sell your practice and join an ACO. You could be a full time salaried doctor. The ACO would do all of the other stuff while you concentrate 100 percent on your patients. No more staff. No more malpractice insurance payments. No more late night phone calls. Regular hours. Scheduled vacations. A pension plan. A 401k plan. Paid holidays. A medical plan. A dental plan. A decent salary. Imagine that!

http://www.facebook.com/bfabbio Bob Fabbio

Even with less patients and a direct-pay business model, it does not mean that the “practice” is able to perform great follow-up and coordination of care. In my mind, that is a function of workflow and clinical automation. There are too many details that are missed or fall through the cracks in many environments. Especially those that are not technology enabled. A significant reliance on technology is a key component that enables WhiteGlove Health to be able to provide medical care that costs less, results in superb clinical outcomes, and gives our members a much higher quality healthcare experience.

http://www.HealthcareMarketingCOE.com/ Simon Sikorski MD

I recently was asked to promote such a “retainer” practice and refused – it’s just another idea many docs will use to increase profits at the cost of patient care. No good can come from charging extra money for a service that can be already sub-par. But because it’s a novel idea and the “sales” reps at the doctor’s office make lofty promises people feel “wow… this is so great” and then get a wake up call when they have to wait 2 weeks to see their doctor again.

http://www.capko.com Laurie Morgan

Interesting … isn’t it also at least sometimes the case that retainer practices have much panels? And that this means getting in to see the doctor is a lot easier? I believe I have heard of some such practices that actually commit to a maximum number of patients to ensure better access (and a more manageable workload for the physicians).

http://twitter.com/bfabbio Bob Fabbio

To us, we think it takes more than business model changes (direct pay). It takes: changes to the consumer experience, changes to the cost structure, changes to the workflow, and more. When all this is done together … then you are changing healthcare.

Matthew Mintz

I want to thank everyone for their comments. Very interesting discussion an commentary. I do want to address davemills555. While ACO’s are definitely around the corner (regardless of who our next President is) and I actually do hope they work, I don’t think they are going to be the panacea that your comments make them out to be. The flaw in your comparisons to Home Depot and Walmart is that the big box stores one out on price. Consumers decided they would go to big box stores instead of supporting Mom and Pop because they could simply get the same stuff for less (and possibly because instead of going to two stores they could go to one). In health care, cost to the patient is neutral. The co-pays are going to be the same whether or not they are going to a single doc PCP practice or a large ACO. Patients may however, prefer having all their care in one system. Patients at Kaiser actually love this. However, the other part where the comparison fails is customer service/time. When consumers made the choice to go to Big Box instead of Mom and Pop, they decided they would sacrifice customer service (have you ever tried to get help finding something at Walmart, let alone having a Walmart employee help you decide which toaster/TV/children’s toy was right for you?). In primary care, this is what the PCP offers:their time, experience and knowledge. This is a lot to give up, especially when cost is neutral. Unfortunately, the current reimbursement model does not value time. This is why some primary care physicians have moved outside the system where their time and expertise is valued. Hopefully, ACO’s will prove that they can provide comprehensive and coordinated care to many. However, similar to Kaiser, this may come at the expense of decreased access, decreased continuity and decreased continuity/time with your own physician.
The other thing I wanted to comment on is that your PCP may be correct that “85 percent of primary care is routine and can be done by an RN or a NP or a PA.” All of these professionals play a vital role in our health care system. However, chronic diseases like diabetes, hypertension, dyslipidemia, asthma, COPD, etc. may be routine, but that doesn’t make them easy. It take a lot of time, effort, energy and experience to work with patients to determine the best treatment regimens and way to ensure adherence. I am not sure that the Big Box ACO will do as well as the single PCP in this area, especially if (by going outside the system via retainer or direct access primary care) they have lots of time to spend with patients and excellent access for follow up.

Anonymous

If we are discussing the high cost of boutique medicine and that such high cost creates a 50 million person segment of our society that can’t afford such expensive treatment, something must change. Most Americans will trade “designer health care” for military style health care if it will get them some sort of treatment and save them some money. Will they see someone other than a doctor? Probably. Will they get less face time? Probably. Will they get less sympathy, less pity and empathetic bedside manner? Probably. Will they pay less money? Yes! Will the 50 million uninsured get a chance to be treated, even if it’s by an RN? Yes! The small office boutique model is unsustainable. It will continue to be unsustainable and grow much worse until providers begin to work on the problem of reducing the 50 million uninsured and the 25 million more that are underinsured we currently have in America. Small office doctors are closed off and isolated from the real problems America faces with out broken system. They are more concerned about making a profit in their tiny little office in their tiny little world. They need to come up out of their hole and breath some fresh air and take look around and see how the real world works. ACOs will begin to force that to happen.

Anonymous

You keep throwing statistics and wild accusations around. where are you getting these? Earlier you mention that “It’s my guess that there are over 50 million uninsured Americans and another estimated 25 million more” is this your guess, or is this a fact. If it is a fact please cite it. Also, please cite any credible source to substantiate your claims about the role of the physician in healthcare cost. Hope you have a great day Dave.

By the way, the “guess” was about whether the uninsured and underinsured even try to get treatment. I wasn’t guessing about the actual number that are uninsured or underinsured. Nice try! However, the numbers are well published “facts”.

Matthew Mintz

Sorry for the typo. Big box stores won out on price.

Anonymous

You know, there are countries who do a far better job of providing overall healthcare at a lower cost than the US does. Sometimes doctors get pissed because they don’t feel they make enough, so do other healthcare professionals. But there doesn’t seem to an exodus of doctors anywhere, or great differences in outcomes of most diseases. When Medicare started, waiting lines were predicted, but they didn’t happen and doctors and hospitals found a bonanza in providing all the medicine you want, no questions asked. It was a long time and is still coming to light that this approach has created much of the debt we have in this country.

Do people come from other countries to the US for their healthcare? – you bettcha – mostly complex stuff that super skilled spinal, GI and some other kinds of docs provides (for the super rich) but on the other hand, for some general stuff – Americans go elsewhere – where there are good physicians and prices are cheaper. I remember years ago, people came from Canada for by- pass surgery (and it was then shown those who didn’t, didn’t die any sooner) or even before ‘hysterectomies” were far more common than now. Outcomes? Humm!

We have tons of waste, corruption, inefficiency, uninsured we need to deal with that other countries have resolved or never had. Read Paul Starr’s latest book – Remedy and Reaction, look at WHO stats about our ranking, look at our Eating Culture. What a mess – yes, plenty of blame to go around.

Switzerland has a kindof concierge insurance plan – so they have some really luxurious hospitals as a result and I am sure that the rich folk can get some preferential treatment. But, for basic care – everyone MUST have an insurance plan and THEY MUST be not-for-profit – this battle was fought and won in the 90s.

It seems to me – all other discussion until we get some basics solved is well, silly. ACOs make sense, having a universal health insurance program makes sense, helping docs with medical school makes sense. We know what should be done and it isn’t “socialism” it’s social democracy to keep this country in business – it can co-exist with capitalism – but capitalism cannot be the base model for healthcare. Notice, I am not using the UK or even France as examples here although France has a healthcare electronic system to, excuse the expression, “die for”.

It’s time to change the status quo, it is time to have universal insuance, it is time for so much better if only our representatives could see the harm they are doing to the country with their squabbling and resistance to change.

Anonymous

Our military personnel already has universal health care. Our Veterans already have universal health care. Our senior citizens already have universal health care. It works for them. It’s time we made it work for the rest of us!

Anonymous

Bottom line? It’s my guess that there are over 50 million uninsured Americans and another estimated 25 million more, all of which get little or no regular medical treatment today, that would trade all of the perks that expensive boutique heath care offers just so they could get to see a Registered Nurse for treatment once in a while.

Anonymous

Blogs are places for open, honest and sometimes very candid and frank discussions. They usually aren’t for the faint of heart. Those who are “delicate” should never participate. The fact of the matter is, we have a health care system that is rigged against the health care consumer. It’s a cancer that’s been growing for decades and that still needs to be cured. Boutique and concierge health care delivery are just band-aids. A system that excludes nearly 1/4th of the American population, either by being uninsured and underinsured, needs major surgery. Our discussions here need to stop putting band-aids on this raging cancer. The stark realities need to be exposed. We need to stop dancing around the edges of the issues and begin the long over due surgery that our health care system needs. Until every American has access to affordable health care, the cancer continues to rage on.

Matthew Mintz

“Blogs are places for open, honest and sometimes very candid and frank discussions.”- Agreed
“We have a health care system that is rigged against the health care consumer.” I would state this differently. One could argue that we have a system that gives the consumer pretty much whatever they want..as long as they have insurance. And you are correct that about 50 million Americans do not have health coverage, which is horrible. Where you are incorrect is that retainer practices have almost nothing to do with this. They are still very uncommon, and since patients are paying out of pocket, do not contribute to the problem. They do however, pose a threat to access if primary care providers decide to leave the system because they find they can not reasonable work within it. Though doctors and hospitals account for most of health care expenditures, it is not the primary care physicians that are running up costs. In fact, most studies show that primary care docs save the system money. The problem is that the PCP’s time is not valued by the current system. Rather, expensive and often unnecessary tests and procedures are what’s running up the bill, and preventing every American from having coverage. The two main drivers of this is a health care system that rewards these service (and not the work of the PCP) and a malpractice system that encourages unnecessary testing.
“Boutique and concierge health care delivery are just band-aids.” “Our discussions here need to stop putting band-aids on this raging cancer.” I would state that retainer practices are a reaction by a few primary care docs that have become utterly frustrated with the system. However, whether or not retainer medicine can be part of a comprehensive overhaul of the system is valid discussion for forums like this. Looking at both extremes, on one side you have a single-payer, government run/funded universal health care system that uses ACO’s and medical centered homes. On the other side you have tax credits for consumers to purchase their own health care. I am not necessarily promoting one side or the other. However, one could argue that part of the problem is that health insurance (in the current system) doesn’t work like auto or home owner insurance. You don’t use your care insurance to pay for gas or minor repairs and maintenance. One suggestion would be to have a high deductible, low cost insurance for emergencies (surgery, injury, cancer treatment) with regular care (primary care) paid out of pocket. In direct access primary care (which as in my original post is a version of retainer medicine), patients pay $40-$70/month for most primary care and urgent care needs and this is usually paired with a high deductible/low cost insurance plan. A little known fact is that in 2014, as part of President Obama’s Affordable Health Care Act, such plans will actually be part of the health exchanges for the uninsured. Thus, I think it is reasonable to have a discussion of whether a retainer like model can be part of the solution. The problem, in my opinion, is when we keep using terms like “concierge” and “boutique” anonymously with retainer medicine, it prevents productive dialogue. This point was the purpose of my original post.

Anonymous

Good post…

I lean toward universal health care that has very strong rules regarding medical effectiveness. The Affordable Care Act (ACA) is as close as we will ever get to universal health care when you consider the insane partisan politics that currently exists in Congress. The key component to the ACA’s success is the individual mandate, originally a Republican idea. Republicans are like children in that because they didn’t get credit for the individual mandate and because a Democratic President got it passed and enacted, now Republicans don’t like it. They want to take their ball and go home. They could not care less about the benefits of the ACA for consumers. They only care about political battles. Fact is, the ACA will be doomed without the individual mandate. The SCOTUS will hear arguments and make a ruling about the individual mandate before the summer of 2012. The insurance companies all favor the individual mandate for obvious reasons. They can write more policies. However, doctors and hospital groups and drug companies are split about their support of the individual mandate. In my opinion, those who make a living in the health care industry had better be praying that the individual mandate is upheld by SCOTUS. These professionals had better get in touch with their members of Congress and push real hard to support the individual mandate. SCOTUS had better hear your voices loud and clear about the need for an individual mandate. It’s our best chance to begin to reverse the cost curve and rescue our health care system and we will only have one shot at it. If SCOTUS rules against the individual mandate, we all had better hunker down and be prepared for the nuclear winter of our broken health care system.

Anonymous

I really want universal care for all- no one – the patient or me should be scrambling to get help for a patient with someone who requires a specialist, medications, or testing,
I am exhausted by the amount of time it takes to coordinated with other doctors, even when the patient does have insurance, and the sheer volume of paperwork- and the EMR seems to shifting an awful lot of this on me!
As for concierge- I signed up for it for myself. Not impressed. Unlikely to renew.